CRITICAL
INFORMATION
APPENDIX
[Insert Name of House of Worship] Facility Safety Assessment Checklist
Assessment Date:00/00/0000 Facility Name: [insert name of house of worship] Primary Contact: [insert name of head of establishment] Assessor:
[Insert Name] Facility Address: [insert facility address] Facility Coordinator: [insert name of facility coordinator]
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Section A: Organization Profile
Criteria Yes/ No/NA Description/Comments
Facility Capacity [total including all buildings on campus]
Facility Campus Type [single building, one story building (s), multi-story, multiple
building(s), etc.]
Type of Building Materials [construction materials: brick, siding, wood, etc.] Total Number of Buildings
Names of Each Building on Campus
Total Number of Floors [each building]
Approximate Total Square Footage [each building=total]
Year of Construction [each building]
Number of Rooms of Each Bldg. #of Exits
Type of Surrounding Community [urban, suburban, rural]
Are the following pieces of equipment and campus locations checked on a regular basis? Fire/Life Safety Systems (i.e., fire pump, fire panel, alarm system) & Life Systems (AED) HVAC Fire suppression Fire extinguishers Smoke/Heat Detectors Generators Security Alarm Kitchen Playground Were mechanical, custodial and electrical rooms found to be locked?
Were all chemicals properly stored, labeled and in their original containers?
Total Number of Congregants # of Adult Congregants # of Youth Congregants # of Staff Members
[Insert Name of House of Worship] Facility Safety Assessment Checklist
Assessment Date:00/00/0000 Facility Name: [insert name of house of worship] Primary Contact: [insert name of head of establishment] Assessor:
[Insert Name] Facility Address: [insert facility address] Facility Coordinator: [insert name of facility coordinator]
Page | 2
Average # of Visitors During Worship Services
Average # of Visitors Daily
Does your House of Worship have an AED machine? If so, do you have people trained to use it? Who?
Names & Credentials of
Congregants who work in Public Safety (law enforcement, fire, EMS)
Local Emergency Management Agency Contact Information
*If available, include a campus map with the Facility Assessment. Section B: Safety Considerations
Criteria Yes/ No/NA Description/Comments
What would you consider the #1
risk to congregant safety? [and human caused hazardsSee Table 1.0, insert applicable day-to-day risks, natural hazards ] What would you consider the #1
risk to staff safety? [and human caused hazardsSee Table 1.0, insert applicable day-to-day risks, natural hazards ] What types of day-to-day
emergencies have occurred at this facility within the last 5 years?
[i.e. fires, power outages, calls to 911,missing children]
What types of natural disasters have occurred within the city, county and surrounding
community over the last 10, 15, 20 years?
What types of technological disasters have occurred within the city, county and surrounding community over the last 10, 15, 20 years?
What types of human caused disasters have occurred in the city, county, state or nation over the last 10, 15, 20 years?
Section C: Visitor/Volunteer/Contractor Protocol
Criteria Yes/ No/NA Description/Comments
Is there a visitor log book or computerized visitor log-in system in the main office?
[Insert Name of House of Worship] Facility Safety Assessment Checklist
Assessment Date:00/00/0000 Facility Name: [insert name of house of worship] Primary Contact: [insert name of head of establishment] Assessor:
[Insert Name] Facility Address: [insert facility address] Facility Coordinator: [insert name of facility coordinator]
Page | 3
and procedures.
Are visitors and vendors escorted on campus?
Do outside
contractors/vendors/janitorial personnel check-in before providing services?
Section D: Emergency Procedures
Criteria Yes/ No/NA Description/Comments
Are safety and security plans updated annually?
Does the house of worship have an anonymous hotline number to report incidents to
administrators?
Are emergency phone number stickers attached to all house of worship facility telephones? Does the house of worship have an automated voice mail system that would be able to relay any messages to congregants inquiring about activities or incidents going on at the house of worship? Has an emergency preparedness
kit been established? [considerations list, flashlights, first aid supplies, radios, etcIncluding, but not limited to: emergency contact lists medical ] Does the house of worship have
an emergency management team? How often do they meet? Have all members of the
Emergency Management Team received a copy of the emergency procedures manual?
Have congregants been notified of what to do if an emergency occurs while the house of worship is in session?
[Insert Name of House of Worship] Facility Safety Assessment Checklist
Assessment Date:00/00/0000 Facility Name: [insert name of house of worship] Primary Contact: [insert name of head of establishment] Assessor:
[Insert Name] Facility Address: [insert facility address] Facility Coordinator: [insert name of facility coordinator]
Page | 4
Section E: Evacuation Procedures
Criteria Yes/ No/NA Description/Comment
How many evacuation drills are performed annually?
Has the fire department participated in any drills at the facility?
Have the evacuation assembly points been established, both on and off campus?
Have transportation needs been addressed if all occupants needs to be relocated to the off campus assembly point?
How far from the campus are the primary assembly points?
How far from the campus are the secondary assembly points? Does the facility have an adequate system to track congregants (especially children) evacuating from the facility?
Does the house of worship have any mutual assistance agreements with other organizations?
[Insert Name of House of Worship] Facility Safety Assessment Checklist
Assessment Date:00/00/0000 Facility Name: [insert name of house of worship] Primary Contact: [insert name of head of establishment] Assessor:
[Insert Name] Facility Address: [insert facility address] Facility Coordinator: [insert name of facility coordinator]
